[Cardiology. I. Heart failure].
To compare the medical treatment of heart failure 30 years ago and at present implies more than the report of new therapeutic strategies and their application. First of all, there is a change in pathophysiological concepts: 30 years ago the therapeutic aim was the increase of myocardial contractility, currently afterload reduction without reactive activation of the sympatho-neuronal and of the renin-angiotensin system is aimed. In contrast to the situation 30 years ago, nowadays new therapeutic strategies can no longer be based on pathophysiological considerations or the demonstration of a potentially beneficial acute effect. The efficacy of any new treatment for heart failure has to be evaluated by controlled randomized trials with the primary end point of prolongation of life. The treatment of chronic heart failure 30 years ago was essentially based on general methods and on the application of diuretics and digitalis. Improved survival of patients with heart failure was first documented by afterload reduction with hydralazine/isosorbide dinitrate. Further improvement was achieved by application of ACE-inhibitors. For diuretics no results are available indicating improved prognosis. For digitalis two studies indicate symptomatic but no prognostic improvement. The treatment of heart failure with betablockers is not yet finally decided. Especially in the post-CAST area the drug treatment of ventricular tachyarrhythmias is very problematic. Class I antiarrhythmic drugs should generally be rather avoided. The application of betablockers or class III antiarrhythmic drugs maybe considered, although there is no proof. In symptomatic patients the implantation of a cardioverter/defibrillator system may be preferred.
Kübler
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Abteilung Innere Medizin III, Klinikum der Universität Heidelberg.
D002309:Cardiology / Q000639:trends*; D006333:Heart Failure / Q000503:physiopathology* / Q000628:therapy; D006801:Humans
Kardiologie. I: Herzinsuffizienz.